Attitudes toward limitation of support in a pediatric intensive care unit

Keenan, Heather T.; Diekema, Douglas S.; O’Rourke, P. Pearl; Cummings, Peter; Woodrum, D. E.

doi:10.1097/00003246-200005000-00055

Cited by 35 publications

(46 citation statements)

References 13 publications

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“…By comparing the data obtained from studies on modes of death conducted at U.S. and Canadian hospitals, it is observed that the incidence of CPR prior to the death of patients at the three analyzed PICUs (53%) was extremely high. 6,10,15 One should recall that CPR is indicated in cases of unexpected cardiorespiratory arrest. A large number of infants who die at PICUs every day have chronic diseases and stand no chance to have their disease controlled.…”

Section: Discussionmentioning

confidence: 99%

“…All the physicians who helped with the research received a previous training before the data collection, in which they had to read classic articles on modes of death in the ICU, followed by simulate cases for the classification of the modes of death and a theoretical lesson on the subject. 5,15 Two sessions were necessary so that the reliability of the data, assessed by kappa statistics, reached 0.9. Data collection only started after this value was reached.…”

Section: Methodsmentioning

confidence: 99%

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Limitação de suporte de vida em três unidades de terapia intensiva pediátrica do sul do Brasil

Lago¹,

Piva²,

Kipper³

et al. 2005

J. Pediatr. (Rio J.)

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Objectives: To describe causes of death and factors involved in the decision-making process related to life support limitation at three university-affiliated pediatric intensive care units in the south of Brazil.Methods: A retrospective study was conducted, based on a review of the medical records of all deaths occurring during 2002 at three pediatric intensive care units in Porto Alegre. Three previously trained pediatric fellows from each service performed the study. Data were assessed relating to general case characteristics, causes of death (failed cardiopulmonary resuscitation, brain death, do-not-resuscitate orders, withholding or withdrawing lifesustaining treatment -the last three modes were classified as the life support limitation group), length of stay in hospital, end-of-life plans and the participation of patients families and Ethics Committees. The Student t test, Mann Whitney, chi-square, odds ratio and multivariate analyses were used for comparisons.Results: Close to 53.3% of fatal cases had received full cardiopulmonary resuscitation. The incidence of life support limitation was 36%, with statistical differences (p = 0.014) between the three hospitals (25 versus 54.3 and 45.5%, respectively). The most frequent form of life support limitation was a do-not-resuscitate order (70%). Life support limitation was associated with the presence of chronic disease (odds ratio = 8.2; 95%CI 3.2-21.3) and length stay in the pediatric intensive care unit (odds ratio = 4.4; 95%CI 1.6-11.8). The rate of involvement of families and Ethics Committees in the decision-making process was lesser than 10%.Conclusions: Cardiopulmonary resuscitation is offered more frequently than is observed in northern countries. In contrast, life support limitation is offered through do-not-resuscitate orders. These findings and the low participation of the families in the decision-making process reflect the difficulties to be overcome by those professionals who are responsible for handling critically ill children in southern Brazil.J Pediatr (Rio J). 2005;81(2):111-7: Death, ethics, pediatric intensive care, forgoing life support, do-notresuscitate orders.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Limitação de suporte de vida em três unidades de terapia intensiva pediátrica do sul do Brasil

Lago¹,

Piva²,

Kipper³

et al. 2005

J. Pediatr. (Rio J.)

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“…11 The revelation about the presence of paralyzing agents in some patients at the time of withdrawal of LST and that 2% of the involved professionals believed that hastening death is an acceptable goal in itself generated great controversy. 12-14 Consequently, more information about pediatric intensivists' actual practices regarding forgoing LST in children 8,10,15,16 is warranted. Some details about these events, such as timing of decision making, terminal sedation, barriers to achieve consensus with families, and their participation in the process, remain topics that need additional exploration.…”

mentioning

confidence: 99%

Circumstances Surrounding End of Life in a Pediatric Intensive Care Unit

2003

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ABSTRACT.Objective. Approximately 60% of deaths in pediatric intensive care units follow limitation or withdrawal of life-sustaining treatment (LST). We aimed to describe the circumstances surrounding decision making and end-of-life care in this setting.Methods. We conducted a prospective, descriptive study based on a survey with the intensivist after every consecutive death during an 8-month period in a single multidisciplinary pediatric intensive care unit. Summary statistics are presented as percentage, mean ؎ standard deviation, or median and range; data are compared using the Mantel-Haenszel test and shown as survival curves.Results. Of the 99 observed deaths, 27 involved failed cardiopulmonary resuscitation; of the remaining 72, 39 followed withdrawal/limitation (W/LT) of LST, 20 were do not resuscitate (DNR), and 13 were brain deaths (BDs). Families initiated discussions about forgoing LST in 24% (17 of 72) of cases. Consensus between caregivers and staff about forgoing LST as the best approach was reached after the first meeting with 51% (35 of 68) of families; 46% (31 of 68) required >2 meetings (4 not reported). In the DNR group, the median time to death after consensus was 24 hours and for W/LT was 3 hours. LST was later withdrawn in 11 of 20 DNR cases. The family was present in 76% (45 of 59) of cases when LST was forgone. The dying patient was held by the family in 78% (35 of 45) of these occasions.Conclusions. More than 1 formal meeting was required to reach consensus with families about forgoing LST in almost half of the patients. Families often held their child at the time of death. The majority of children died quickly after the end-of-life decision was made. In pediatric ICUs (PICUs), retrospective studies done during the past decade indicate that 40% to 60% of all deaths follow such a decision. [3][4][5][6][7] However, few of these reports describe how these decisions were reached. 7-10 A more recent study analyzed 53 deaths in 3 PICUs in the United States in which LST was forgone. The author's focus was on the medications given at the end of life and the physicians' and nurses' levels of satisfaction with the care provided. 11 The revelation about the presence of paralyzing agents in some patients at the time of withdrawal of LST and that 2% of the involved professionals believed that hastening death is an acceptable goal in itself generated great controversy. 12-14 Consequently, more information about pediatric intensivists' actual practices regarding forgoing LST in children 8,10,15,16 is warranted. Some details about these events, such as timing of decision making, terminal sedation, barriers to achieve consensus with families, and their participation in the process, remain topics that need additional exploration. 17,18 The purpose of this study was not only to determine the modes of death in a single large multidisciplinary PICU in Canada but also to describe the decision-making process and the end-of-life care. We also examined the level of difficulty to reach consensus with families or ...

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“…Further, nurses were asked what type of end-of-life decision they considered the most important made. In nearly half of the end-of-life decisions (49%), a nontreatment decision www.ajcconline.org (89) 70 (50) 41 (29) 30 (21) 50 (35) 35 (25) 23 (16) 33 (23) 0 (0) 135 (96) 6 (4) NA NA NA NA NA NA NA NA NA NA NA 14 (16) 74 (84) 52 (58) 22 (25) 15 (17) 34 (38) 21 (24) 20 (22) 14 (16) 3 (3) 84 (94) 2 (2) 24 (27) 14 (16) 3 (3) 13 (15) 16 (18) 19 (21) 25 (28) 35 (39) 29 (33) 62 (70) 27 (30) Abbreviation: NA, not available. a Percentages may not total 100 because of rounding.…”

Section: Medical End-of-life Decisions In Picusmentioning

confidence: 99%

“…This result is also in keeping with previous findings. 28,32,33 Furthermore, nurses consider the involvement of parents in the decision to be important. 27 Apparently, PICU nurses comply with international guidelines that state that decisions should be jointly made by physicians and parents.…”

Section: Nurses' Attitudes Toward End-of-life Decisionsmentioning

confidence: 99%

Medical End-of-Life Decisions: Experiences and Attitudes of Belgian Pediatric Intensive Care Nurses

Inghelbrecht¹,

Bilsen²,

Pereth³

et al. 2009

American Journal of Critical Care

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Objective To investigate Belgian pediatric intensive care nurses' involvement in and attitudes toward medical end-of-life decisions with a possible or certain life-shortening effect. Methods Questionnaires were distributed to 141 nurses working in 5 of the 7 pediatric intensive care units in Belgium. Nurses were asked to recall the last child in their care whose treatment involved an end-of-life decision and to describe anonymously their involvement in the decision. Attitudes were ascertained by means of statements and a Likert scale. Results Questionnaires were completed by 89 nurses (63%). During the preceding 2 years, 76 (85%) had cared for at least 1 child for whom a medical end-of-life decision had been made. Nurses were involved in initiating the decision in 17% of cases, participated in decision making in 50%, and played a role in carrying out the decision in 90%. Only 6% of nurses found it always ethically wrong to hasten the death of a child by administering lethal drugs; most nurses (78%) reported they were prepared to cooperate in administering life-ending drugs in some cases. Most (89%) favored adapting the law, making life termination of children legally possible in certain cases. Conclusions Belgian pediatric intensive care nurses are often involved in carrying out medical end-of-life decisions, including administration of life-ending drugs, whereas their participation in decision making is more limited. Most think that the current euthanasia law should be extended to minors so that administering life-ending drugs would be possible for terminally ill children in specific circumstances.

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Attitudes toward limitation of support in a pediatric intensive care unit

Abstract: When making decisions about whether or not to limit care for a patient, caregivers were more likely to rely on the perceived benefit to the patient than preadmission quality of life.

Cited by 35 publications

References 13 publications

Limitação de suporte de vida em três unidades de terapia intensiva pediátrica do sul do Brasil

Limitação de suporte de vida em três unidades de terapia intensiva pediátrica do sul do Brasil

Circumstances Surrounding End of Life in a Pediatric Intensive Care Unit

Medical End-of-Life Decisions: Experiences and Attitudes of Belgian Pediatric Intensive Care Nurses

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